- My Forms at Home

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Phone #

Type

Ext

Phone #

Type

Ext

Phone #

Type

Ext

Phone #

Type

Ext

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

GENDER PRONOUNS

Date of birth:

What are your pronouns?

She/Her

He/His

They/Their

DENTAL INFORMATION

In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. During your initial visit, you may be asked questions about your responses to this questionnaire, and additional questions concerning your health may be requested.

MEDICAL INFORMATION

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking, and your health history have an important relationship with your dental treatment. Please answer the following questions:

Please, go over the following section and indicate which of the following you have or have had.

CHILDREN ONLY

Please list any medical conditions or illnesses the child has recently had. This can include measles, strep throat, tonsillitis.

DON'T TYPE HERE. FOR DENTIST USE ONLY

Signature

Patient, Parent or Guardian Signature for Medical and Dental History and General Information

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

I authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to Jeffery Edwards/Byronwood Dental Office.

This authorization shall continue in effect until the undersigned revokes the same.

Signature of Patient, Parent or Guard

INSURANCE DISCLAIMER

INSURANCE DISCLAIMER
You may have questions regarding your dental insurance plan as a patient receiving dental care in this office. Members of our staff, who are familiar with dental insurance, may be able to answer most of your questions. But, since individual plans offer unique benefits and restrictions, they may not be able to provide you with all the answers. However, because we deal with hundreds of insurances, we cannot be accountable for an error we may make. As the policyholder, you must review and understand your insurance before treatment. We recommend that you read your insurance booklet thoroughly and ask questions of your company’s representative so that you do not have any surprises in meeting your dental treatment obligations - for example, waiting periods or downgraded coverage of white fillings on back teeth.
In addition, your dentist is responsible for treating your dental problem appropriately. Treatment plans are not based on whether or not you have dental insurance. You will be provided with a description of your treatment plan with an estimate of your total fee. If you undertake this treatment, you will be responsible for payment of the total fee even if the insurance company denies payment.
Finally, please be aware that dental insurance is, in fact, not insurance in a true sense, such as life or auto insurance. It is, instead, a third-party (supplemental) payment. Our office policy is that patients are responsible for checking coverage before dental treatment, and payment is expected upon completion of treatment.

I have read, understand, and agree with the above insurance disclaimer. Patient, Parent or Guardian Signature for Insurance Disclaimer.

PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION.

Privacy of your personal information is essential to our office, providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.
Dr. Jeffery L. Edwards acts as the Privacy Information Officer in this office.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information you have disclosed. They are all trained in the appropriate uses and protection of your information.
Attached to this consent form, we have outlined what our office is doing to ensure that:
- Only necessary information is collected about you.
- We only share your information with your consent.
- Storage, retention and destruction of your personal information comply with existing legislation and privacy protection protocols.
- Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with any office staff member.  Please be assured that every staff in our office is committed to ensuring you receive the best quality dental care.
How Our Office Collects, Uses and Discloses Patients’ Personal Information
Our office understands the importance of protecting your personal information. To help you know how we are doing that, we have outlined how our office uses and discloses your information.
This office will collect, use and disclose information about you for the following purposes:
- to deliver safe and efficient patient care
- to identify and ensure continuous, high-quality service
- to assess your health needs
- to provide health care
- to advise you of treatment options
- to enable us to contact you
- to establish and maintain communication with you
- to offer and provide treatment, care and services for the oral and maxillofacial complex and dental care generally
- to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and peripheral dentists
- to allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
- to allow us to follow up for treatment, care and billing efficiently
- for teaching and demonstrating purposes on an anonymous basis
- to complete and submit dental claims for third-party adjudication and payment
- to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
- to comply with agreements/undertakings entered into voluntarily by the member of the Royal College of Dental Surgeons of Ontario, including the delivery and review of patient charts and records to the College in a timely fashion for regulatory and monitoring purposes
- to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
- to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
- to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
- to prepare materials for the Health Professions Appeal and Review Board (HPARB)
- to invoice for goods and services
- to process credit card payments
- to collect unpaid account
- to assist this office in complying with all regulatory requirements
- to comply generally with the law.
By signing the consent section of this Patient Consent Form, you have agreed to give your informed consent to the collection, use and/or disclosure of your personal information for the purposes listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.
Regulatory authorities may access your information under the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA and for the defense of a legal issue.
Our office will not supply your insurer with your confidential medical history under any conditions. If this kind of request is made, we will forward the information directly to you for review and your specific consent.
We will contact you for permission to release such information when unusual requests are received.
We may also advise you if such a release is inappropriate.
You may withdraw your consent to use or disclose your personal information, and we will explain the ramifications of that decision and the process.

I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information. I agree that Byronwood Dental Office can collect, use and disclose personal information about the patient who signs this form as set out above in the information about the office's privacy policies.

Print the Name of the Patient, Parent or Legal Guardian for the Consent Form:

Signature of Patient, Parent or Legal Guardian for Consent Form

Date

Witness of signature for Consent Form

CANADA ANTI-SPAM LEGISLATION (CASL)

Canada’s Anti-Spam Legislation (CASL) requires that we obtain your express consent to send you information electronically. To subscribe to receiving information electronically, please provide your consent by signing this document. You can withdraw your consent at any time by providing notice in writing.

Signature of Patient, Parent or Legal Guardian For CASL

AUTHORIZATION FOR EMAIL AND TEXT COMMUNICATION

Byronwood Dental Office uses a modern system for confirming appointments and offering reminders by emails and text messages. We send a save-the-date invitation after one day you book your appointment. We also send a communication for recall (periodontal maintenance + dentist examination) 30 days before, for general confirmations nine days before, and a reminder one day before your appointment. Furthermore, we provide a reminder if you are 60 days overdue. You may unsubscribe from this service at any time. Would you like to enroll in this program?

Yes

No

Text Message

Email

It does not matter

Signature of Patient, Parent or Legal Guardian for Email and Text Communication